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� ' SNOHOMISH HEALTH DtSTRICT <br />Water/Wastewater Section <br />3020 RuckerAvenue N104 <br />Everett WA 982013900 <br />425.339.5250 <br />�% <br />REQUEST P'OR R�PORT ON AN ��� <br />ONSITL' SGWAGG DISPOSAT. SYSTEM <br />�ChecL• hox if application includes Water Report Requ �t <br />and attach completcd application � <br />PropertyTaxAccounttl C'����9�D�»n�' �'� ��Q - <br />Property Address �� � �n `> ��� ���- `��- _ Ciry �•l1 L�f 77� <br />MAIL/ftEPORT TO• �"�se clearlv orint (ul��r:9� <br />/ � comolete aadl�tcludinn zio c�g, > <br />l <br />��t� I �� 1�1 �1 �Ti-tlS�"�u <br />; u'>e,,t 9`'� .Oe :�_ - <br />�u���rr- �rr� �S�Ud' <br />S /4c�' E'�.A '%� 3`� ��-' �'ti!HOwA� NAR.mS �.� <br />noT ��a�in <br />UNLESS <br />APPLICA'CION <br />IS DATF. K FEE <br />5'(AMPGD ItY <br />S�OHODTI511 <br />itr•.ni:r�i <br />n�s•r�t�c�r <br />3�K ��o� <br />Legai Descnption: Sec. �'�9 Twp. ��� Rng. G� �ol N n-� � <br />SHD OFFICE llSE ONLY <br />F4 Iliiu'i �i.?i�.f'� <br />�nr:,i i�o.c��, <br />i.i1�: .; �77ii.(Yii <br />i:Hi�idf,r i�.i:i� <br />rrr-n � <br />„�,:�r iri .,,,. �� i�•�:-� <br />i <br />Appl�canPsName_ � Gt'_f-��� �.-���'�S7F�t�r,r�, Phone �/:,2.5 -�SS'--C:�L��� Ce�GE� <br />O�vnersName `,,l.rl�- Phone_ �/�5 - ,3 �� -/��;7iC i1c.�n•t�. <br />Is house occupied? �J Yes ❑ No If not, date vacated <br />Year house built �`� bn C' Number of bedrooms � <br />Date septic tank last pumped %�� �`� S Pumped by��� F f- f�; � ��-1� 11 %17-i [N`.� <br />Has the septic system failed or mal(unctioned? ❑Yes �No �xplain <br />Has the septic system been repaired or altered? ❑Yes �No <br />Sin�e new, has the home had any additions? �Yes ❑No Describe �� �+L.�� f- YJ �-�� � �t�-c .ili � � iic <br />ApplicantSignature ����*�-�e�ec �—�L�:��-Z�'s>�.c,>rt Date ��b� <br />NOTE: Any /ield insp�tion conducted hereunder is Iimiled to a visual inspection o/ the site to observe signs of septic <br />system iailure present on the ground surlace or surlace water, and visible physical leatures which may impair the proper <br />operation o/ the septic system. This report does not constitute a representation, warranry, or guarantee as to whether or <br />not the system is actually Iunctioning at this time, nor representation or warranty as fo the luture lunctioning o/ the sewage <br />disposal system. <br />For Hcalth District Usc Only <br />Fieid Inspection Date /� ���L �L� � As-Built on lile. � As-Built not on file. <br />1. � Sewage disposal system appears to be functioning at time of inspection. <br />2. 0 Sewage disposal system appears to he malfunctioning at time of inspection (owner to be notitied). <br />3. O Home vacant at time of inspection, system not in operation. <br />4. �J Snohomish Heallh Dicrri�i records indicate lhat the septic lank has nol been pumped within the last 2 1/2 - 3 years. <br />5. f� There appears lo be a ponion ` d� �� ��P�� <br />T��c/,��oc��-�,o �/.c��� ��- sD�c.� �rc� f-/o> >uc� <br />Comments <br />Signed a�� �l�' ✓ Date �� ���L O� <br />Environm al alihDivision IID27rcv0?ISWj <br />1, ..\�` <br />W✓ <br />